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How district health decision-making is shaped within decentralised contexts: a qualitative research in Malawi, Uganda and Ghana

Bulthuis, Susan E. and Kok, Maryse C. and Amon, Samuel and Agyemang, Samuel Agyei and Nsabagasani, Xavier and Sanudi, Lifah and Raven, Joanna and Finn, Mairead and Gerold, Jana and Tulloch, Olivia and Dieleman, Marjolein A.. (2021) How district health decision-making is shaped within decentralised contexts: a qualitative research in Malawi, Uganda and Ghana. Global public health, 16 (1). pp. 120-135.

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Abstract

District Health Management Teams (DHMTs) are often entry points for the implementation of health interventions. Insight into decision-making and power relationships at district level could assist DHMTs to make better use of their decision space. This study explored how district-level health system decision-making is shaped by power dynamics in different decentralised contexts in Ghana, Malawi and Uganda. In-depth interviews took place with national- and district-level stakeholders. To unravel how power dynamics influence decision-making, the Arts and Van Tatenhove (2004) framework was applied. In Ghana and Malawi, the national-level Ministry of Health substantially influenced district-level decision-making, because of dispositional power based on financial resources and hierarchy. In Uganda and Malawi, devolution led to decision-making being strongly influenced by relational power, in the form of politics, particularly by district-level political bodies. Structural power based on societal structures was less visible, however, the origin, ethnicity or gender of decision-makers could make them more or less credible, thereby influencing distribution of power. As a result of these different power dynamics, DHMTs experienced a narrow decision space and expressed feelings of disempowerment. DHMTs' decision-making power can be expanded through using their unique insights into the health realities of their districts and through joint collaborations with political bodies.
Faculties and Departments:09 Associated Institutions > Swiss Tropical and Public Health Institute (Swiss TPH)
09 Associated Institutions > Swiss Tropical and Public Health Institute (Swiss TPH) > Department of Swiss Centre for International Health (SCIH) > Systems Strengthening and Health Promotion (Prytherch)
UniBasel Contributors:Gerold, Jana
Item Type:Article, refereed
Article Subtype:Research Article
ISSN:1744-1706
Note:Publication type according to Uni Basel Research Database: Journal article
Language:English
Identification Number:
edoc DOI:
Last Modified:19 Dec 2022 09:56
Deposited On:19 Dec 2022 09:56

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